1. Where Have All the Health Workers Gone? Malawi’s Response

2. Presentation Outline Malawi’s Response Challenges and Trends Lessons Emerging Impact and Sustainability

3. Challenges and Trends Challenges and Trends In 2000: 20% of Malawian nurses; 60% of Malawian doctors worked abroad. 2004 vacancy rates for critical cadres: - Surgeons: 98% - Pathologists: 100% - Medical specialists: 95% - Obstetricians: 92% Lack of domestic/international support for MOH HRH Plan finalized in 2000

4. Why did this happen? Insufficient production of health workers Low and declining pay (e.g., 2001/02 average HW wage in real terms was less than half that in 1980) Poor non-financial terms and conditions Poor recruitment practices in public sector Crumbling health system – poor support to staff Devastating impact of HIV/AIDS

5. Malawi’s Response New government in 2004: fiscal discipline Increased commitment to health sector In turn: ◦ donor confidence enhanced ◦ increased preparedness to fund recurrent expenditure ◦ momentum for health sector wide “systems approach”

6. Malawi’s Response: Policy Interventions 2004: six-year, $272m Emergency Human Resources Program (EHRP) was developed EHRP nested within the SWAp mechanism Task shifting: incl. use of community health workers Reintroduction of Medical Assistants cadre Revitalization of the CBD Program Introduction of LTPM in pre service curricula

7. Emergency Human Resource Program 1. Expand training capacity by 50% on average 2. Improve retention and re-engagement, 52% taxed top-ups for 11 key cadres of GoM and CHAM staff, recruitment and re-engagement program, bonding initiative, rural location incentives, staff housing 3. Stop-gap external support for critical posts (mostly teaching) - 50 volunteer doctors, nurse tutors per year while Malawians staff trained 4. MOH HR management support: 3 TA for 2yrs 5. M&E – linked to SWAp M&E framework

8. Task shifting CBDAs providing contraceptives in the community Nurses/ MA providing LTPM at HC level HSAs providing immunizations and health promotion activities including; injectable contraceptives and village clinics at the community NB- No client satisfaction surveys done on all task shifting.

9. Incentives for Community Workers HSAs on government payroll Protective wear; umbrella, raincoats Bicycles Community support Recognition and acknowledgement by influential leaders Promotion to CBDA supervisor Performance based awards (Project Specific) Money for an IGA activity appropriate to the community.

10. Impact Improved health worker ratios: physicians from 1.1 (2004) to 1.9 (2007); nurses and midwives from 25.5 to 34 Reduced nurse emigration: from 147 (2004) to 23 (2006), to 8 (2007) Training targets approx being met – falling short of nurse/midwife targets, exceeding doctor/clinical officer/med asst targets

11. System Impact: Quality Assurance Pre and in-service training Refresher trainings and annual reviews Field supervisors conduct weekly visits Monthly/ Quarterly Supervision by program staff Data management Linkages and referrals Concerns on loading too much on HSAs

12. Impact: Supervision of Community Health workers Levels Primary level: by Senior CBDA/HSA-1:15 Secondary level: Service Provider/Program Coordinator National level: RHU; FBO;NGO; Private Sector Frequency: Monthly by Primary Supervisor; Quarterly by secondary supervisor; National supervisor once per year.

13. Sustainability EHRP- modest but promising results Use of salaried field staff such as HSAs Volunteer turnover – depends on incentives All activities steered by central Ministry or Districts for continuity Streamlined reporting requirements-one LMIS Standardized guidelines & training materials Community ownership of volunteers Strong supervisory system at community level

14. Emerging Lessons Political and donor commitment: willingness to support wage bill for EHRP; allow different pay scales sector; concerns about sustainability Taking a systems approach: only makes sense within overall context of improving health service facilities and management systems. Phased approach: combination of short and long term and stop gap measures Deployment: address delays in getting recruits on payroll CBD Services: concerns about sustainability Pre-service Vs In-service: balancing needs careful managing No clear defined role of VHW

15. ZIKOMO Thank you